Provider Demographics
NPI:1275042558
Name:GOLDMAN, JACLYN (LSW)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 N WELLS ST APT 1801
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-6015
Mailing Address - Country:US
Mailing Address - Phone:847-641-0811
Mailing Address - Fax:
Practice Address - Street 1:1636 N WELLS ST APT 1801
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-6015
Practice Address - Country:US
Practice Address - Phone:847-641-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.102640104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker